Post-traumatic stress disorder (PTSD) is typically characterised by intrusive recollections of a traumatic event, enhanced arousal and affective numbness. Other symptoms may occur, such as depressive, dissociative and psychotic symptoms, leading to a significant clinical heterogeneity.
A 39-year-old man developed PTSD and schizoaffective disorder depressive type one year after a stressing event marked by extreme violence. He was prescribed with valproic acid 2 g per day and clozapine 800 mg per day, but because of the presence of a series of symptoms, such as anxiety, insomnia, anhedonia and blunted affect, lorazepam 6 mg per day and sertraline 50 mg per day were added. Despite the combination of drugs, the response was only partial and he evolved with progressive deterioration of intrusive and psychotic symptoms, including first-rank Schneiderian symptoms such as commanding voices and suicidal ideation. He was submitted to a comprehensive neuropsychological evaluation that was unrevealing.
In our psychiatric outpatient clinic (Raul Soares Institute, Belo Horizonte, Brazil), there are other 11 cases with similar clinical features described for the above-mentioned patient. They include male gender, victim of physical aggression and history of other previous traumatic events, suicidality, poor insight, depressive symptoms with blunted affect. Interestingly, they had been diagnosed with a long series of psychiatric disorders, such as bipolar disorder, factitious disorder, dissociative disorder, borderline personality disorder and PTSD. They were also using similar pharmacological schemes, including mood stabilisers, atypical antipsychotics, benzodiazepines and serotonergic antidepressants. Despite treatment, these patients evolved with clinical deterioration marked by anhedonia, first-rank symptoms and social isolation.
Some questions emerge from these clinical observations. First, why did these cases receive so many clinical diagnoses? We believe that this may not reflect poor clinical expertise considering that these diagnoses were performed by well-trained and experienced psychiatrists. Maybe they truly represent pure PTSD. Alternatively, cumulative traumatic events could have triggered psychosis. This is in line with the diathesis-stress model of schizophrenia, i.e. stress fostered a psychotic process in vulnerable subjects. In genetically predisposed individuals with dysfunctional hypothalamic-pituitary axis, abnormal release of cortisol following a stressful situation would lead to dopaminergic activation and, as a consequence, to the development of psychotic symptoms Reference Walker, Mittal and Tessner(1). Indeed, there is a growing body of evidence establishing an association between PTSD and psychosis.
For instance, associations were found between negative schematic beliefs, PTSD and predisposition to both paranoia and hallucinations. While PTSD re-experiencing symptoms were strongly associated with a predisposition to hallucinations, negative beliefs about self and others were most associated with a predisposition to paranoia Reference Gracie, Freeman and Green(2). Studies assessing cognition in elderly people with schizophrenia have described greater compromise in subjects exposed to more stressful events Reference Goodman, Finkel and Naser(3). Suicidality in schizophrenia has been also associated with traumatic experiences Reference Strauss, Calhoun and Marx(4). Some authors even suggest that the presence of psychotic symptoms in patients suffering from PTSD may represent an under-recognised and unique subtype of PTSD. Psychotic symptoms in PTSD are associated with a more severe level of psychopathology similar to that found in chronic schizophrenia Reference Lindley, Carlson and Sheikh(5).
In our view, however, there is no one single entity to accommodate such PTSD cases marked by severe and persistent blunted affect and psychotic symptoms following recurrent traumatic events of violence. Thus, in many cases, the diagnosis of the schizoaffective disorder was given as no better option to describe the picture of persistent depressive alike symptoms concomitant with first-rank psychotic symptoms is available in the current classificatory models. One further reason to consider them unique is their lack of clinical response to all strategies used, involving antidepressants, mood-stabilising agents and atypical antipsychotics.
Extrapolating PTSD epidemiological data derived from the North American population, it is estimated that almost 7 million Brazilian inhabitants have or are prone to develop this disorder Reference Mello, Mello and Kohn(6). This picture may be even worse if the high indices of urban violence in Brazil are taken into account. It would be of great value to determine the percentage of this vulnerable population evolving with a psychotic disorder. It also remains to be clearly defined whether abating violence indices or early treating these patients would prevent clinical deterioration and psychotic development.
